Hillary Mei Galiza

April 07, 2014

Clinical Instructor: J. Rosao
!"aluation
1. In#ection
$utco%e &1 ' (atient re%ains #ree o# in#ection, as e"ience )y nor%al "ital si*ns an a)sence
o# purulent raina*e #ro% +ouns, incisions, an tu)es.
,o %easure t-is outco%e, I +ill %a.e sure t-at t-e patient/s "ital si*ns are ta.en at least
t+ice e"ery s-i#t, to %a.e sure t-ere aren/t any %a0or c-an*es. I +ill also c-ec. )ot- t-e incision
site at t-e -ip an t-e I1 site at t-e #oot to %a.e sure t-ere are no si*ns o# in#ection, suc- as
reness, s+ellin*, purulent raina*e, in#iltration, etc. ,-is assess%ent is on*oin*, an on %y
s-i#t, t-is outco%e +as %et )ecause t-ere +ere no si*ns o# in#ection as %entione a)o"e.
$utco%e &2 ' (atient %aintains )loo *lucose an *lycosolate -e%o*lo)in le"els +it-in
e#ine tar*et ran*es.
,i*-t *lucose control is "ital in t-is case )ecause 2ia)etes puts a patient at ris. #or
#urt-er in#ection. Accorin* to 2r. 3o-',ri"ei, 4In#ections account #or 556 o# postoperati"e
co%plications an nearly one 7uarter o# perioperati"e eat-s in patients +it- 2M. 2ata su**est
i%paire leu.ocyte #unction, incluin* altere c-e%ota8is an p-a*ocytic acti"ity9 :Mescape,
201;<. (er 2octor/s orers, I -elpe to acco%plis- t-is *oal )y oin* a #in*er'stic. )loo
*lucose c-ec. )e#ore %eals an at )eti%e, an )y a%inisterin* insulin as appropriate. $n t-e
#irst ay o# +or.in* +it- %y patient, -is )loo *lucose reac-e t-e -i*- 200/s, -o+e"er +-en
c-ec.e t-e ne8t ay, it +as in t-e lo+ 100/s. I +oul say t-at t-is *oal is not yet #ully %et, )ut is
in t-e process o# i%pro"in*. As #or t-e patient/s H)A1c :11.1<, t-is is so%et-in* t-at ta.es a)out
; %ont-s to see t-e e##ects o#. =ecause t-e patient is -a"in* )etter *lucose control no+, I +oul
su**est c-ec.in* t-e H)A1c le"els ; %ont-s #ro% no+ to see i# it i%pro"e.
$utco%e &; ' (atient re%ains co%#orta)le, #ree o# pain.
=ecause t-is outco%e is su)0ecti"e, I +oul -a"e to "er)ally as. t-e patient an assess
-is responses in orer to %easure t-is outco%e. I +oul 0ust as. -i% -o+ -e is #eelin*, an i# -e
nees anyt-in* at t-e %o%ent. Assessin* #or pain is also so%et-in* I +oul #re7uently o as I
+al. into t-e roo% e"ery ti%e. >pon %y s-i#t, I +oul say t-at t-is outco%e +as in t-e process
o# )ein* %et, )ecause as t-e patient e8perience pain, I respone appropriately an -elpe t-e
patient to *et co%#orta)le.
2. (ain
$utco%e &1 ' (atient reports satis#actory pain control at a le"el less t-an ; to 4 on a 0 to 10
ratin* scale.
,o %easure t-is outco%e, I +oul constantly as. t-e patient to report -is pain le"el on a
scale o# 0'10, +it- 0 )ein* no pain, an 10 )ein* t-e +orse pain -e/s e"ery #elt. 2epenin* on
-is response, I +oul as. i# -e neee %e to o so%et-in*, suc- as -elp -i% c-an*e positions,
a%inister pain %eication, etc., in orer #or -i% to *et co%#orta)le. ,-is assess%ent is an
on*oin* one, an urin* %y s-i#t, I +oul say t-at it +as in t-e process o# )ein* %et )ecause %y
patient/s ratin*s "arie e"ery once in a +-ile, epenin* on -is acti"ity.
$utco%e &2 ' (atient uses p-ar%acolo*ical an nonp-ar%acolo*ical pain'relie# strate*ies.
2epenin* t-e patient/s response to %y pain assess%ent, eter%ine +-at I +oul o
ne8t. I# it +as a lo+ ratin* t-at +as )eara)le an relie"a)le +it- rest an eep )reat-in*, I
encoura*e -i% to o so. I# not, I o##ere pain %eication, an a%inistere it +it- -is nurse.
,-is outco%e is consiere as %et, )ecause t-e patient oes use )ot- p-ar%acolo*ical an
nonp-ar%acolo*ical pain'relie# strate*ies, epenin* on t-e type o# pain #elt.
;. I%%o)ility:
$utco%e &1 ' (atient per#or%s p-ysical acti"ity inepenently or +it-in li%its o# conition.
,o %easure t-is outco%e, I +oul assess t-e patient/s a)ility to a%)ulate or )ear +ei*-t.
,-en +-en *ettin* up to an*le on t-e sie o# t-e )e, or to use t-e co%%oe, I +oul let t-e
patient o as %uc- as -e can on -is o+n, an assist only +-en neee. ,-is %a.es -i% put e##ort
into tryin* to )e inepenent as %uc- as possi)le. ,-is outco%e is a +or. in pro*ress, an +ill
soon )e %et +it- %ore %o)ility an e8ercises +it- (, an $,.
$utco%e &2 ' (atient e%onstrates use o# aapti"e tec-ni7ues t-at pro%ote a%)ulation an
trans#errin*
2urin* %y s-i#ts o# +or.in* +it- t-e patient, I notice t-at -e +as a)le to sit up #ro%
lyin* position, t-en to an*lin* -is #eet on t-e sie o# t-e )e, all )y -is sel#. Alt-ou*- -e is not
a)le to #ully a%)ulate on -is o+n yet, t-e patient e%onstrates t-at -e is tryin* -is )est to %o"e
on -is o+n as %uc- as possi)le, so t-at -e isn/t 0ust layin* in one position t-e +-ole ti%e. At t-is
point, I +oul say t-at t-is outco%e is %et, an I a% sure t-at t-e patient +ill continue to +or.
on t-is *oal.
$utco%e &; ' (atient is #ree o# co%plications o# i%%o)ility, as e"ience )y intact s.in, a)sence
o# t-ro%)op-le)itis, nor%al )o+el pattern, an clear )reat- souns.
,o eter%ine t-e pro*ress o# t-is outco%e, I +oul )rie#ly per#or% s.in, GI, per#usion,
an respiratory assess%ents. =ecause %y patient is +ea. an partially i%%o)ile, -e is at ris. #or
co%plications suc- as s.in tears, constipation, 21,s, an aspiration. Monitorin* #or t-ese t-in*s
an early etection +ill pre"ent #urt-er co%plications. ?o #ar, t-is outco%e is %et )ecause t-e
patient i not e8-i)it any o# t-ese si*ns, -o+e"er on*oin* assess%ent is neee.
4. !li%ination
$utco%e &1 ' (atient passes so#t, #or%e stool at a #re7uency percei"e as 4nor%al9 )y t-e
patient
,o %easure t-is outco%e, I +oul care#ully %onitor t-e patient/ s )o+el pattern an
per#or% an in'ept- GI assess%ent. 2urin* %y s-i#t, t-e patient only -a one )o+el %o"e%ent,
+-ic- +as pure li7ui. (er patient, it +as t-e only )o+el %o"e%ent since -e/s -a t-e sur*ery :;
ays earlier<, an -e oes #eel constipate. He also -a positi"e )o+el souns an positi"e #latus.
=ecause o# t-is #inin*, t-e nurse su**este t-at it coul )e #ecal i%paction an a%inistere t-e
orere la8ati"e an stool so#teners. ,-is speci#ic outco%e +as t-ere#ore not %et.
$utco%e &2 ' (atient is nor%o"ole%ic as e"ience )y urinary output *reater t-an or e7ual to
;0%3@-r, )alance inta.e an output, sta)le +ei*-t, a)sence or reuction o# ee%a, -eart rate
less t-an 100)eats@%in, a)sence o# crac.les.
,o eter%ine +-et-er t-is outco%e is %et or not, I +oul o care#ul %onitorin* o# t-e
patient/s IA$s, ee%a, -eart rate, an lun* souns. >pon %y s-i#t, I i not notice any si*ns an
sy%pto%s o# #lui i%)alances. ?o t-is outco%e +as %et at t-e ti%e. Ho+e"er +-en I c-ec.e
t-e patient/s c-art a couple +ee.s later, ee%a an acute .iney #ailure +as note. Bro% t-is
point, I +oul say t-at t-is outco%e is not %et, )ut is a +or. in pro*ress as #luis an 3asi8 +ere
*i"en, an t-e 2octor orere an anti)iotic c-an*e to lessen .iney a%a*e.
C. Altere nutrition@Blui A electrolyte i%)alance
$utco%e &1 ' (atient e%onstrates appropriate selection o# %eals or %enu plannin* to+ar t-e
*oal o# +ei*-t reuction
,o eter%ine t-e pro*ress o# t-is outco%e, I +oul assess +-at t-e patient is orerin* on
-is trays an +-at -e is eatin*. Bro% t-e ays t-at I +as ta.in* care o# t-is patient, I collecte
lunc- trays t-at +ere e%pty, an -a receipts #ro% ietary statin* 4cariac iet9, as t-at is +-at
is orere #or t-e patient. Ho+e"er, #or inner, t-e patient/s #a%ily co%es to "isit an )rin*s #oo
#or -i% to eat, an t-ey +eren/t "ery %in#ul o# -is iet +-en c-oosin* +-at #oos to )rin*.
=ecause t-e patient +oul #eel )a i# -e in/t eat +-at -is #a%ily )rou*-t, -e +ante to s-o+
consieration )y at least eatin* a s%all portion. In aition, t-e patient %ae sure t-at -e as.e
t-e nurse i# it +as o. to o so )e#ore -an. ,-is s-o+s t-at t-e patient +as puttin* e##ort into
stic.in* to -is iet, e"en t-ou*- t-ere +ere so%e circu%stances -olin* -i% )ac.. I +oul say
t-at t-is outco%e #or t-e %ost part, is %et )ecause t-e patient oes try -is )est.
$utco%e &2 ' (atient +ill -a"e nor%al .iney #unction as e"ience )y nor%al =>D an
creatinine la) "alues.
,-e only +ay to %easure t-is outco%e is to ra+ la)s an +ait #or t-e results. $"er ti%e,
%y patient/s creatinine le"els ele"ate up to 2.;, an -e e8-i)ite ee%a on -is lo+er
e8tre%ities. ,-e 2octor sai t-at t-ese si*ns %i*-t -a"e )een )ecause o# t-e "anco%ycin t-at t-e
patient +as recei"in*. ,-is +as t-en later iscontinue, an t-e patient recei"e o8acillin
instea. ,-ere +ere not #ollo+ up la)s note, so I t-in. t-at t-is outco%e is partially %et, an in
t-e process o# )ein* i%pro"e.
5. I%paire s.in inte*rity
$utco%e &1 ' (atient/s s.in re%ains intact, as e"ience )y no reness o"er pro%inences an
capillary re#ill less t-an 5 secons o"er areas o# reness.
,o eter%ine t-e pro*ress o# t-is outco%e, a #ull s.in an per#usion assess%ent is
neee. >pon a "isual inspection o# t-e s.in, I #oun no si*ni#icant reness, an t-e patient/s
capillary re#ill +as al+ays less t-an ; secons on all #our e8tre%ities, ECM?. ?ince t-ere are no
si*ns o# i%paire s.in inte*rity )esies t-e incision site an I1 site, I +oul say t-at t-is
outco%e is consiere %et.
$utco%e &2 ' (atient/s incision an I1 site +ill re%ain #ree o# in#ection.
,-is outco%e is %easure )y constant "isual inspecte o# t-e sur*ical site :le#t -ip< an
t-e I1 site :ri*-t #oot<, %a.in* sure t-at t-ere isn/t any reness, s+ellin*, pain, raina*e,
in#iltration, -eat, etc. >pon %y s-i#t, %y patient i not s-o+ any o# t-ese si*ns, t-ere#ore t-is
outco%e is %et.